Missed Psychotropic and COPD Medications Due to Pharmacy Ordering Failure
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when multiple newly ordered medications were not administered over several days because they were not available from the pharmacy. The resident was admitted with COPD, depression, and bipolar disorder and had new physician orders initiated for Divalproex Sodium 1000 mg at bedtime for bipolar disorder, Olanzapine 2.5 mg at bedtime for bipolar disorder, and Trelegy Ellipta one puff daily for COPD. Medication Administration Records (MARs) for several days in February showed these medications were not given, with chart codes referencing progress notes that documented the medications were “on order.” For Divalproex Sodium, the February MAR showed missed doses on two separate days by the same nurse, who documented in medication administration notes that the medication was on order and therefore not administered. For Olanzapine, the MAR showed missed doses on three consecutive days by two different nurses, each documenting in medication administration notes that the medication was on order and not available to administer. For Trelegy Ellipta, the MAR showed missed doses on four consecutive days by three different nurses, with notes on three of those days stating the medication was on order; there was no corresponding medication administration note for one of the missed days. Nursing documentation also showed the resident was on 2 L/min oxygen via nasal cannula with even, unlabored respirations during this period. Interviews confirmed that nursing staff did not administer the Divalproex Sodium, Olanzapine, and Trelegy Ellipta because the medications had not arrived from the pharmacy and were considered to be on order. The resident reported that he did not have his inhaler and a couple of other medications when he first arrived and that it took a few days before he received all of his medications. A nurse practitioner progress note documented that the resident was seen for a follow-up visit related to missing medications and that he had missed doses of Trelegy, Valproic Acid, and Olanzapine after admission. The nurse practitioner stated that interruption of Depakote and Olanzapine could cause mood instability and increased behaviors, and omission of Trelegy could cause increased breathing issues, and that the medications should have been administered as ordered.
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